The Pulse

Plugging the leaks

There are plenty of treatments for incontinence in women, but few of them actually work, US researchers have found.

Published 20/03/2008

[Image source: iStockphoto]

It's a common condition, and very embarrassing. Urinary incontinence affects about one woman in five, usually older women who've given birth.

In most cases it's caused by leakage of urine during exertion  when coughing, sneezing, laughing or lifting heavy objects, or during physical activity.

It's known as 'stress' incontinence and it happens because these activities increase pressure in the bladder, which forces urine through the urethra.

Normally, the sphincter around the urethra stops the leakage, but in some women, usually following childbirth, the sphincter is weakened and the urine can escape.

During pregnancy, hormonal changes and the extra weight and pressure of the baby contribute to weakening. The pelvic floor muscles may also be weakened during childbirth, especially after a prolonged labour, if the baby is large, or following a forceps delivery.

Incontinence is also more common after the menopause because the reduction in oestrogen levels weakens the muscle tone in the urethra.

Less common, but also distressing, is 'urge' incontinence  a sudden and urgent desire to urinate caused by an overactive bladder muscle.

Unfortunately most women with incontinence  about 60 per cent  simply put up with it, thinking it's an inevitable consequence of having children and getting older. There is a plethora of treatments available  pelvic floor exercises, bladder training, various drugs, devices placed in the vagina, hormone replacement therapy and even surgery. How do you and your doctor know what's best?

Well, recently some researchers from the University of Minnesota School of Public Health looked at all the available scientific evidence to answer this question. They looked at 96 good-quality studies published between 1990 and 2007, which examined the effects of various non-surgical treatments for stress and urge incontinence, and both types combined, in women for periods up to a year after treatment.

Pelvic exercises

By far the most effective treatment, they found, is a combination of pelvic floor training with bladder training.

Pelvic floor training is a common treatment for stress incontinence, and is best learned from a GP, physiotherapist, or nursing staff trained to teach the technique. It involves strengthening the pelvic floor muscles through actively tightening and lifting them at intervals. It needs to be done five to six times a day, and takes two to three months to work, but is very effective when done in combination with bladder training, the researchers found.

Bladder training, a common treatment for urge incontinence, involves delaying urination and urinating to a schedule, gradually increasing the length of time between toilet visits.

Most cases of incontinence are cured by the combination of both, the study found. Pelvic floor training alone is effective too, but not as much as the combination, which is more effective because most cases of incontinence involve elements of both urge and stress incontinence.

Other treatments not so effective

Another treatment approach is to use vaginal cones. A woman places a cone inside the vagina, and contracts her pelvic floor muscles to hold the cone in place, thus strengthening the pelvic muscles. But the researchers didn't find much evidence that they work.

Some drugs  notably the anticholinergic drugs  are used to treat urge incontinence. They work by inhibiting bladder contractions, though they may cause side effects like dry mouth, constipation and blurred vision. The researchers found that oxybutynin (brand names Ditropan and Oxytrol) and tolterodine (Detrusitol)  both anticholinergics  are effective, but adrenergic drugs aren't. The long-term benefits or dangers of using medications to treat incontinence aren't clear.

Another approach is to inject bulking agents  collagen, fat or a synthetic material  into the tissues around the urethra to narrow the opening. But again, there's no real evidence that this works.

Other treatments found to have little effect include electrical stimulation  in which small pulses of electricity are supposed to generate pelvic muscle contractions  and biofeedback  using a sensor to measure pelvic floor muscle contractions, giving feedback about how strong the contractions are.